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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801786
Report Date: 11/22/2024
Date Signed: 11/24/2024 11:24:48 PM

Document Has Been Signed on 11/24/2024 11:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:ANGEL'S CREST HOMEFACILITY NUMBER:
486801786
ADMINISTRATOR/
DIRECTOR:
FABIE, MARIVIEFACILITY TYPE:
740
ADDRESS:258 DARLEY DRIVETELEPHONE:
(707) 644-3687
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 3DATE:
11/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH: Administrator, Marivie FabieTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Canela arrived unannounced, to conduct an Annual Required 1 YR inspection and was greeted by care staff, Lourdes Valdez, Administrator, Marivie Fabie was called and arrived a few minutes later.

LPA toured the facility and made the following observations: the facility was a comfortable temperature. Extra hygiene products and linens were available and required bath mats and grab bars were observed. Water temperature in residents' bathrooms measured at 113 degrees F which is within regulation. Cleaning products and other toxins are locked and located under the sink in kitchen. Resident rooms were furnished per regulation. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked.

Fire extinguishers were last inspected 10/23/24. Smoke detectors located throughout the facility and carbon monoxide detector were tested and functional. Last Disaster Drill conducted on 9/28/24. Fire Dept. conducted annual inspection on 11/5/2024. Exit doors have auditory alert system that were functional at time of visit. Required postings were observed. LPA initiated file review of 3 Residents and 2 Staff records. Administrator Certificate for Marivie Fabie, 6021180740, expires on 11/29/2024. Staff have required First Aid and CPR certificates expiring 9/2/25. Training records were reviewed. Residents have medical assessments and needs and services plans are updated.


continue report see LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ANGEL'S CREST HOME
FACILITY NUMBER: 486801786
VISIT DATE: 11/22/2024
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LPA requested the following updated records to be submitted to Community Care Licensing by 12/22/2024

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 610D Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of current, updated facility Sketch and request any changes for review
· Copy of Liability insurance

Exit interview conducted with Marivie Fabie, Licensee/Administrator.
No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC809 (FAS) - (06/04)
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